1992938203 NPI number — MRS. MELISSA ROSE MORA D.O

Table of content: MRS. MELISSA ROSE MORA D.O (NPI 1992938203)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992938203 NPI number — MRS. MELISSA ROSE MORA D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MORA
Provider First Name:
MELISSA
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992938203
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12008 S SHORE BLVD
Provider Second Line Business Mailing Address:
SUITE 108
Provider Business Mailing Address City Name:
WELLINGTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33414-6395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8188 S JOG RD STE 205
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOYNTON BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33472-2952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-231-5200
Provider Business Practice Location Address Fax Number:
561-231-5210
Provider Enumeration Date:
09/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  OS11560 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 112125600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com